• You ask us to pay for a prescription drug you have received.
• You ask for a Part D drug that is not on your plan sponsor's list of covered drugs (called a formulary). This is a request for a formulary exception. See "What is an exception?" below for more information about the exception process.
• You ask for an exception to our utilization management tools, such as prior authorization, dosage limits, quantity limits, or step therapy requirements. Requesting an exception to a utilization management tool is a type of formulary exception. See "What is an exception?" below for more information about the exception process.
• You ask for a non-preferred Part D drug at the preferred cost-sharing level. This is a request for a tiering exception. See "What is an exception?" below for more information about the exception process.
• You ask us to pay you back for the cost of the drug you bought at an out-of-network pharmacy. In certain circumstances, out-of-network purchases, including drugs provided to you in a physician's office, will be covered by the Plan. 

What is an exception?

An exception is a type of initial determination (also called a coverage determination) involving a Part D drug. You or your doctor may ask us to make an exception to our Part D coverage rules in a number of situations.
 

• You may ask us to cover your Part D drug even if it is not on our formulary. Excluded drugs cannot be covered by a Part D plan.
• You may ask us to waive coverage restrictions or limits on your Part D drug. For example, for certain Part D drugs, we limit the amount of the drug that we will cover. If your Part D drug has a quantity limit, you may ask us to waive the limit and cover more.
• You may ask us to provide a higher level of coverage for your Part D drug. If your Part D drug is continued in our non-preferred brand (Tier 3) tier, you may ask us to cover it at the cost-sharing amount that applies to drugs and the preferred brand (Tier 2) tier instead. This would lower the coinsurance/co-payment amount you must pay for your Part D drug. Please note if we grant your request to cover a Part D drug that is not on our formulary, you may not ask us to provide a higher level of coverage for the drug. Also, you may not ask us to provide a higher level of coverage for Part D drugs that are in the specialty (Tier 4) tier.

Who may ask for an initial determination?

You, your prescribing physician, or someone you name may ask us for an initial determination. The person you name would be your appointed representative. You may name a relative, friend, advocate, doctor or anyone else to act for you. Other persons may already be authorized under state law to act for you. If you want someone to act for you who is not already authorized under state law, then you and that person must sign and date a statement that gives the person legal permission to be your appointed representative.

The Appointment of Representation form can be found below. This form gives the person legal permission to act as your appointed representative. This statement must be faxed or mailed to us at the designated number or address below.

Appointment of Representation Form

Upon receipt of all the necessary information needed to review an initial determination, standard initial determination decisions will be made within 72 hours. Fast initial determination decisions will be made within 24 hours.

To begin an initial determination request, please call Customer Service at 1-888-547-5252 (TTD/TTY users, call 1-888-816-5252) Monday - Sunday, 7:00 a.m. - 2:00 a.m. Eastern Standard Time.


The forms below can be used to request an initial determination by mail or fax.

WellCare Medicare Coverage Determination Request Form

WellCare Injectable Infusion Form
 

Medicare Part D Coverage Determination Request Form

An initial determination request can be mailed to:

 

WellCare Health Plans

Attention: Pharmacy Department

P.O. Box  31577

Tampa , FL 33631-3577

 

You can fax an initial determination request to 1-866-388-1767.

Please click here to access the Evidence of Coverage for more detailed information on all appeals and grievance policies. 

To learn more about the importance of reporting adverse events, product problems and product use errors, please visit FDA Medwatch Reporting.

Appeal Level 1: Appeal to the Plan 
 

An appeal is any of the procedures that deal with the review of an adverse (unfavorable) coverage determination.

You may ask us to review our initial determination, even if only part of our decision is not what you requested. An appeal to the plan about a Part D drug is also called a plan redetermination. When we receive your request to review the initial determination, we give the request to people at our organization who are not involved in making the initial determination. This helps ensure that we will give your request a fresh look.

If you are appealing an initial decision about a Part D drug, you or your representative may file a standard appeal request, or you, your representative, or your doctor may file a fast appeal request. Please see "Who may ask for an initial determination?" above, for information about appointing a representative. 

You must file the appeal request within 60 calendar days from the date included on the notice of our initial determination. We may give you more time if you have a good reason for missing the deadline.

 

How to file your appeal:
 

• Asking for a standard appeal – To ask for a standard appeal about your Part D drug, a signed, written appeal request must be sent to the address listed below.
  You may also ask for a standard appeal by calling us at the phone number listed below. We will give you our decision within 7 calendar days of receiving the appeal request.
• Asking for a fast appeal – If you are appealing a decision we made about giving you a Part D drug that you have not yet received, you and/or your doctor will need to decide if you need a fast appeal. The rules about asking for a fast appeal are the same as the rules for asking for a fast initial determination. You, your doctor, or your representative may ask us for a fast appeal by calling or writing to the numbers or address listed below. We will give you our decision within 72 hours after we receiving the appeal request.

To file an appeal, you, your representative, or your doctor can contact Customer Service at 1-888-547-5252 (TTD/TTY users, call 1-888-816-5252) Monday - Sunday, 7:00 a.m. - 2:00 a.m. Eastern Standard Time, or a written request can be delivered to:

 

WellCare Health Plans

Attention PDP Appeals

P.O. Box  31383

Tampa , FL 33631

 

If you, your appointed representative, or prescribing physician would like to file an appeal via fax, please fax the request to 1-866-388-1766.

 

The following forms may be used to request an appeal.

 

WellCare Medicare Redetermination Request Form

WellCare Provider/Physician Appeal Form

Please click here to access the Evidence of Coverage for more detailed information on all appeals and grievance policies.

Appeal Level 2: Independent Review Entity (IRE)

At the second level of appeal, your appeal is reviewed by an outside, Independent Review Entity (IRE) that has a contract with the Centers for Medicare & Medicaid Services (CMS), the government agency that runs the Medicare program. The IRE has no connection to us. You have the right to ask us for a copy of your case file that we sent to this entity.

If you asked for Part D drugs or payment for Part D drugs and we did not rule completely in your favor at Appeal Level 1, you may file an appeal with the IRE. If you choose to appeal you must send the appeal request to the IRE. The decision you receive from the plan (Appeal Level 1) will tell you how to file this appeal, including who can file the appeal and how soon it must be filed.

You must make a request for review by the IRE in writing within 60 calendar days after the date you were notified of the decision on your first appeal. The IRE has the same amount of time to make its decision as the plan had at Appeal Level 1.

 

If the IRE decides completely in your favor:

The IRE will tell you in writing about its decision and the reasons for it.
 

• For a decision to pay you back for a Part D drug you have already paid for and received, we must send payment to you within 30 calendar days from the date we receive notice reversing our decision.
• For a standard decision about a Part D drug you have not yet received, we must cover the Part D drug you asked for within 72 hours after we receive notice reversing our decision.
• For a fast decision about a Part D drug you have not yet received, we must cover the Part D drug you asked for within 24 hours after we receive notice reversing our decision.

You must send your written request to the Independent Review Entity whose name and address is included in the redetermination notice and on the form below.

Medicare Reconsideration Request Form

Please click here to access the Evidence of Coverage for more detailed information on all appeals and grievance policies. 

Grievances

A grievance is any complaint, other than one that involves a request for an initial determination or an appeal as described above.

Grievances do not involve problems related to approving or paying for Part D drugs.

Who may file a grievance?

You or someone you name may file a grievance. The person you name would be your representative. You may name a relative, friend, lawyer, advocate, doctor or anyone else to act for you. Other persons may already be authorized by the court or in accordance with state law to act for you. If you want someone to act for you who is not already authorized by the court or under state law, then you and that person must sign and date a statement that gives the person legal permission to be your representative.

The Appointment of Representation form can be found below. This form gives the person legal permission to act as your appointed representative. This statement must be faxed or mailed to us at the designated number or address. This completed form must be included with each grievance.

Appointment of Representation Form
 

If you have concerns or problems related to your prescription drug coverage, we encourage you to contact us. We will try to resolve any complaint by phone.  Please call Customer Service at 1-888-547-5252 (TTD/TTY users, call 1-888-816-5252) Monday - Sunday, 7:00 a.m. - 2:00 a.m. Eastern Standard Time.

You may also send your complaint in writing to:

WellCare PDP
Grievance Department
PO Box 31384
Tampa, FL  33631-3384

Grievances can be faxed to: 1-866-388-1769.

A standard grievance is resolved within 30 days from the date of submission. A grievance can be submitted by telephone or in writing by mailing your request to the address listed above.

An expedited grievance can be submitted by calling 1-888-547-5252 (TTY/TTD users call 1-888-816-5252) Monday - Sunday, 7:00 a.m. - 2:00 a.m. Eastern. An expedited grievance is resolved within 24 hours. A grievance coordinator will contact you and/or your representative with a resolution.

The grievance must be submitted within 60 days of the event or incident. We must address your grievance as quickly as your case requires based on your health status, but no later than 30 days after receiving your complaint. We may extend the time frame by up to 14 days if you ask for the extension, or if we justify a need for additional information and the delay is in your best interest. If we deny your grievance in whole or in part, our written decision will explain why we denied it, and will tell you about any dispute resolution options you may have. 

Please click here to access the Evidence of Coverage for more detailed information on all appeals and grievance policies.